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HomeMy WebLinkAboutBLD-23-005795 y i Ottice Use Only �, /� N. :. • o l I b^7/ ��"1 f Z3 Permit# �I"►�a`7 O . ;IA . H !Amount 6-o.ad (JTTA i MACM fSE,,� � +<„`°"`f'��c Permit expires 180 days from issue date 8LP -a&-AO5795 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 —6"'. --- (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: '�' F Ulf 5 Pe --- c53 (, ai- ASSESSOR'S INFORMATION: 1 Map: Parcel: NAi PRESENT ADDRESS TEL. # CONTRACTOR: Joe King NAME 36 Checkerbernptana ADDRESS TEL.# West Yarmouth, MA 02673 "�Residential Commer Est. Cost of Construction$ `CZSO` F l©ne: u8-775-6448 Home Improvement Contractor Lic.# / j O q Construction Supervisor Lic.# C..SS[. - D��CC. Workman's Compensation Insuranc : (check one) I am the homeownerI am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares iffr Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing j *The debris will be disposed of at: 1/ A 1 ( V S- C a-ct G ". Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license an or prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /�.C/ Date: ""( ' Owners Signature(or attach a rE \ —� Date: - J g 'z3• Approved By: Date: / l !"Z, Building Official(or gn EMAIL ADD S: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: If Yes O No I Yes 1 No %, The Commonwealth of Massachusetts iq'"....- i L Department oflndustrialAccidents i I Congress Street, Suite 100 Boston, MA 02114-2017 0,M,.5v•`'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Joe King Name (Business/Organization/Individual). 36 (,heCkerberry Lane Address: West Yarmouth, MA 02673 Phone: 508-775-6448 City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): I._ I am a employer with employees(full and/or part-time).* — 7. _ New construction 2. I am a sole proprietor or partnership and have no employees working for me in ny capacity. [No workers'comp. insurance required.] 8• Remodeling 3.L I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 L Demolition 4.C I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.7 Electrical repairs or additions proprietors with no employees. 12.—Plumbing repairs or additions 5.—I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance. 1 3•—Roof repairs 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 1 Other 5 t r iv, 152,§1(4),and we have no employees. [No workers'comp. insurance required.] d *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy 4 or Self-ins. Lic. 4: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 4-1 1, Z� -��' Date: Phone: 7 7.r fl if L Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License f Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: THE COMMONWEALTH.... ... ... .. ... ..... OF MASSACHUSETTS Office of Consumer A r •• &Business Regulation n. b the,� 9 Registration valid for Individual use only before HOME IMPRO 41�� ONTRACTOR '' expiration date. If found return to: rs drm ,1%. Office of Consumer Affairs and Business Regulation , , e •r 1000 Washington Street -Suite 710 °'. Boston,MA 02118 �ASEPH E.KING t b�P a ., DSEPH E.KING ' 3 CHECKERBERRY L '.`, 7-7- ,a E 1 ,,,,:i., /EST YARMOUTH,MA o , ` ,"° a Commonwealth of Massachusetts ' lilt Division of Occupational Licensure Board of Building Re ulations and Standards Construct i t fi' r Specialty CSSL-099166 c' * pires 01/24/2024 JOSEPH E IG " ` 36 CHECKE E 'w .: WEST YARMOI ,• ' "t Commissioner dii•• K. D�vncLe& • • •